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Case Studies

Case Study 1: Final report on Lockhart River aviation accident

The thorough investigation of a fatal accident near Lockhart River in Queensland shows how the Australian Transport Safety Bureau (ATSB) is helping to improve the safety of Australian aviation.

In May 2005, a mechanically serviceable Fairchild Metroliner aircraft, operated by Transair, was unintentionally flown into a mountain ridge while on approach to Lockhart River Airport. The accident occurred in poor weather during a satellite-based instrument approach, probably because the crew lost situational awareness in low cloud. Both pilots and all 13 passengers were killed.

An ATSB team of up to 12 investigators devoted nearly two years of painstaking work to investigating the accident, producing three factual reports, a research report and 10 safety recommendations, and encouraging other safety actions, before completing the final report and 10 final recommendations. The task was complicated by the lack of an operative cockpit voice recorder or witnesses, and the extent of the destruction of the aircraft.

The comprehensive final report spells out numerous safety factors that the ATSB considers contributed to the accident, in relation to:

  • the actions of the pilots, including that the experienced pilot-in-command had a history of using approach and descent speeds and a rate of descent greater than specified in the Transair Operations Manual, and that the young co-pilot was not adequately trained in complex instrument approaches;
  • the actions of the operator, including significant limitations with Transair's pilot training and checking, supervision of flight operations, standard operating procedures for pilots and safety management processes; and
  • the actions of the regulator, including that the Civil Aviation Safety Authority (CASA) did not provide sufficient guidance to its inspectors to enable them to effectively and consistently evaluate several key aspects of operators' management systems.

The ATSB also identified other safety issues which could not be as clearly linked to the accident because of limited evidence. These included shortcomings in the design of the navigation chart used and the possibility of poor crew communication in the cockpit.

VH-TFU at Bamaga aerodrome on a previous flight
VH-TFU at Bamaga aerodrome on a previous flight (Photo DOTARS)

In its final report, the ATSB issued seven recommendations to CASA, on its regulatory oversight activities and requirements, and three recommendations to Airservices Australia and Jeppesen on aspects of instrument approach charts.

CASA, Airservices Australia and Jeppesen have responded to the recommendations, and other aviation organisations have used the information arising from this major investigation to identify and address safety issues in their own operations. The work of the ATSB is helping the aviation industry to ensure that such an accident will not happen again.

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